Gingivitis and Periodontal Disease last adjusments.pptx

gingival diseases

1. Gingivitis and Periodontal Disease Ph.D. Candidate: Basheer Ali Mabkhot Unde r supervision of: Prof. Dr. Hani

2. ILOS Current classification of periodontal diseases and conditions. Staging and grading of periodontitis. Eruption gingivitis Dental biofilm-induced gingivitis— gingivitis caused by biofilm (bacteria) Allergy and gingival inflammation . Chronic nonspecific gingivitis Acute gingival disease: Oral herpes simplex virus infection Recurrent apthous ulcer (canker sore) Necrotizing gingivitis. Acute candidiasis (thrush, candidosis , moniliasis ) Acute bacterial infections

3. ILOS Gingival diseases modified by systemic factors: Gingival diseases associated with the endocrine system Gingival lesions of genetic origin Phenytoin-induced gingival overgrowth Ascorbic acid deficiency gingivitis (scorbutic gingivitis) Periodontal diseases in children: Periodontitis (previously called aggressive periodontitis and earlyonset periodontitis) Generalized periodontitis (previously called generalized aggresive periodontitis) Periodontitis with molar-incisor distribution (previously called localized aggressive periodontitis and localized juvenile periodontitis) Treatment of generalized periodontitis and periodontitis with a molar-incisor distribution

4. Current classification of periodontal diseases conditions American Academy of Periodontology (AAP) and the European Federation of Periodontology ( EFP) published new classification of periodontal and peri -implant diseases and conditions in 2017. Periodontal health and gingival diseases: Periodontal and gingival health. Gingivitis caused by biofilm (bacteria). Gingivitis not caused by biofilm. Periodontitis: Necrotizing diseases. Periodontitis as a manifestation of systemic disease. Periodontitis Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, Blanco J, Camargo PM. Classification of Periodontal and Peri -Implant Diseases and Conditions. J Periodontol . 2018;89:S313-8 .

5. Other conditions affecting the periodontium: Systemic diseases affecting the periodontium. Periodontal abscess or periodontal/endodontic lesions Mucogingival deformities and conditions. Traumatic occlusal forces. Tooth- and prosthesis-related factors Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, Blanco J, Camargo PM. Classification of Periodontal and Peri-Implant Diseases and Conditions. J Periodontol. 2018;89:S313-8.

6. Staging of Periodontitis . Stage I (Initial ): Clinical attachment loss (CAL):  1-2 mm at the site of greatest loss Bone loss (BL):  <15% in the coronal third of the root only Tooth loss:   None Probing depths:  ≤4 mm with the bone being mostly horizontal BL (Fig . 15.1A and B ). Stage II ( Moderate): Clinical attachment loss (CAL):  3-4 mm at the site of greatest loss Bone loss (BL):   15%–33% in the coronal third of the root. Probing depths:   ≤5 mm with mostly horizontal BL. American Academy of Pediatric Dentistry. Classification of periodontal diseases in infants, children, adolescents, and individuals with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:493-507

7. Stage III ( Severe): Clinical attachment loss (CAL):  ≥ 5 mm at the site of greatest loss Bone loss (BL):   ≥ 3 mm vertical bone loss, and class 2 or 3 furcation involvement. Tooth loss:   ≤ 4 teeth associated with moderate ridge defects. Stage IV ( Severe), Along with all the features of stage III: masticatory dysfunction secondary occlusal trauma severe ridge defects bite collapse pathologic migration of teeth/ the presence of fewer than 20 remaining teeth (10 opposing pairs ). American Academy of Pediatric Dentistry. Classification of periodontal diseases in infants, children, adolescents, and individuals with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:493-507

8. Grading of Periodontitis. Grade A (Slow progression ): No significant bone loss or clinical attachment loss (CAL) within 5 years. Bone loss relative to age is < 0.25. Heavy biofilm but minimal destruction. Non-smoker with controlled blood sugar levels and not diagnosed with diabetes . Grade B (Moderate progression) < 2 mm of bone loss or CAL within 5 years. Bone loss relative to age is between 0.25 and 1.0. Smokes less than 10 cigarettes per day. biofilm is commensurate with the extent of destruction. glycated hemoglobin ( HbA1c) is less than 7%. American Academy of Pediatric Dentistry. Classification of periodontal diseases in infants, children, adolescents, and individuals with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:493-507

9. Grade C (Rapid progression): >2 mm of bone loss or CAL within 5 years. Destruction exceeds biofilm amount. Smokes more than 10 cigarettes per day. HbA1c is ≥7 % Extent and distribution of periodontitis: Localized BL:  <30 % of teeth have bone loss. Generalized BL:  ≥ 30 % of teeth have bone loss. Molar-incisor BL: Bone loss affects the molars (often the first molars) and incisors. American Academy of Pediatric Dentistry. Classification of periodontal diseases in infants, children, adolescents, and individuals with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:493-507

10. Periodontal and Gingival Health Periodontal and gingival health: <10% bleeding sites, PD ≤3 mm Gingivitis : ≥10% bleeding sites, PD ≤3 mm Localized gingivitis: 10%-30% bleeding sites Generalized gingivitis: >30% bleeding sites Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

11. Eruption Gingivitis During the eruption of primary teeth Transitory gingivitis localized and associated with difficult eruption. subsides after the teeth emerge into the oral cavity During the eruption of permanent teeth: Plaque around erupting teeth causes inflammation. It mostly associated with t he eruption of the first, second, and third permanent molars. Mild eruption gingivitis: no treatment, only proper oral hygiene regimen . can develop into pericoronitis or a pericoronal abscess causing pain Pericoronitis is managed by removing the plaque and irrigating the area with Peroxyl . Pericoronitis with swelling and lymph node involvement: should be treated with antibiotic therapy. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

12. Dental Biofilm-Induced Gingivitis—Gingivitis Caused by Biofilm (Bacteria) The amount of plaque and the inflammatory are related. Good oral hygiene reduces plaque and inflammation. Favorable occlusion and chewing of coarse detergent type foods, such as raw carrots and apples, have a beneficial effect on oral cleanliness . Gingivitis associated with poor oral hygiene is classified as early (slight) , moderate , or advanced . Early gingivitis is reversible and treated with good oral hygiene (Figs . 15.6 and 15.7A and B). Gingivitis is generally less severe in children than in adults with similar plaque levels. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

13. Allergy and Gingival Inflammation A study of children with allergies to birch pollen found that they had more gingival inflammation during the pollen seasons. The authors suggest that patients with allergies for longer periods of time may be at higher risk for more serious periodontal problems. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

14. Acute Gingival Disease Oral herpes simplex virus infection: Primary herpes simplex: occurs in unexposed children under 6 While most infections are subclinical, some children develop acute herpetic gingivostomatitis with symptoms like fiery red gingival tissues , malaise , irritability , headache , and pain from acidic food or drinks . Diagnosis can be made based on: T he clinical appearance of the ulcers. four-fold rise in serum antibodies to HSV-1 Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

15. O ral findings of HSV-1: yellow or white liquid-filled vesicles. In a few days, the vesicles rupture and form painful ulcers that 1–3 mm in diameter and covered with a whitish gray membrane with a circumscribed area of inflammation ( Fig. 15.9A and B). Location: The ulcers may appear anywhere in the mouth  but are most common on the buccal mucosa ,  tongue,   lips , and palate. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

16. recurrent herpes labialis (RHL): After primary attack, virus becomes inactive and resides in sensory nerve ganglia . It reappears later as the familiar cold sore or fever blister , usually on the outside of the lips (Fig. 15.10A–C). The recurrence is related: E motional stress. lowered tissue resistance resulting from various types of trauma. Excessive exposure to sunlight irritation from the rubber dam material or even routine daily oral hygiene procedures. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

17. HSV-1 can spread from the mouth to other parts of the body , causing Herpetic whitlow in thumb-sucking children . It usually clears up in two weeks . To reduce the spread of HSV-1 : Stop the child from scratching or picking at the blisters. Don't share toys or utensils. Wash the child's hands often. Caregivers should avoid contact with infants under 6 months or immunocompromised individuals." Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

18. Treatment of acute herpetic gingivostomatitis in children : Palliative treatment (10-14 days ): Relieve acute symptoms to maintain fluid and nutritional intake: This can be achieved through: Topical anesthesia: Dyclonine hydrochloride (0.5%; Dyclone ):  Before meals to temporarily relieve pain and allow the child to eat soft food.  Should not be used more than 4 times per day . Lidocaine (Xylocaine Viscous):  For children who can hold 1 teaspoon of the anesthetic in their mouth for 2-3 minutes and then expectorate the solution Avoid acidic foods and drinks: Can irritate the ulcerated area and lead to pain and discomfort. Vitamin supplements: To maintain a nutritional balance until the lesions have resolved. Consult with the pediatrician to ensure the child is receiving the appropriate nutrients Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

19. Definitive treatment: Systemic antiviral medication (acyclovir,  famciclovir , and valacyclovir ). Systemic analgesics (acetaminophen or ibuprofen ). Acyclovir: Administered in five daily doses to equal 1000 mg/day for 10 days. Available in capsules or suspension. Used in infants and children . Famciclovir and valacyclovir : Newer and possibly more effective antiviral agents. Use in pediatric populations has not yet been studied . Recurrent herpes simplex labialis (RHL) in children aged 12 years and older: FDA-approved treatment:  Valacyclovir 2 g initially, and 2 g 12 hours later. Other recommendations: Bed rest and isolation from other children in the family. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

20. Topical antiviral agents for herpes simplex labialis in children aged 12 years and older : Penciclovir cream: Apply to perioral lesions, not intraoral lesions. Avoid concurrent use with systemic antivirals. Apply every 2 hours while awake for 4 days. 5% acyclovir cream: Apply five times daily for 4 days Docosanol (over-the-counter): does not affect viral replication. Instead, it inhibits the fusion of the HSV-1 viral envelope to the host cell membrane, thereby blocking viral entry into the cell . Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

21. RECURRENT APTHOUS ULCER Names: The recurrent aphthous ulcer ( RAU) recurrent aphthous stomatitis (RAS ) canker sore It is a painful ulceration on the unattached mucous membrane . Occur: in school-aged children and adults. The peak age: 10 - 19 years. The prevalence of RAU: 2% - 50 %. The prevalence of RAU among medical and dental students: 50 % - 60% Ulcers last 4-12 days and heal without scars, except in rare cases Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

22. Clinical features: a round to oval crateriform base. Circumscribed. erythematous margins. pain. The cause of RAU is unknown, but potential causes including: Local factors: Trauma, allergy to toothpaste,  and salivary gland dysfunction Systemic factors: Nutritional deficiencies (iron, vitamin B12, and folic acid), stress delayed hypersensitivity to the L form of Streptococcus sanguis an autoimmune reaction of the oral epithelium. genetic predisposition, as evidenced associations with interleukin genotypes and sometimes a family history . Herpes simplex virus, human herpesvirus type 6, cytomegalovirus, Epstein-Barr virus, and varicella-zoster virus Overall, the cause of RAU is complex and l multifactorial Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

23. They may appear as minor or single. major or multiple. herpetiform lesions . The major form of RAU (RAS) is less common and has been associated with other systemic diseases: PFAPA (periodic fever, aphthous stomatitis, pharyngitis, adenitis ). Behçet disease, Crohn’s disease, ulcerative colitis, celiac disease. neutropenia , immunodeficiency syndromes, Reiter’s syndrome, systemic lupus erythematosus. MAGIC (mouth and genital ulcers with inflamed cartilage) syndrome Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

24. current treatment for recurrent aphthous ulcers (RAU ): Reduce ulcer duration and pain Maintain nutritional intake Promote ulcer healing Prevent or reduce the recurrence T reatment line: Topical corticosteroids ,  such as: 0.5 % fluocinonide. 0.025 % triamcinolone. 0.5 % clobetasol . Topical anesthesia: Orabase Note: before meals and before sleeping may also be helpful. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

25. Topical rinses: Sucralfate Tetracycline Chlorhexidine Dexamethasone elixir (for ulcers in areas of the mouth that are difficult to access ) Severe cases: Oral prednisone (glucocorticoid medication) Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

26. NECROTIZING GINGIVITIS The 2017 AAP/EFP World Workshop removed the word "ulcerative" from the name of this disease because tissue ulceration is secondary to the necrosis   that takes place in necrotizing periodontal disease It is a rare, infectious, acute, necrotizing form of periodontal disease. Occurs in: Children aged 6–12 years. Young adults with immunocompromised ,  chronic psychological stress, or severe malnutrition . feature Necrotizing Gingivitis (NG) Necrotizing Periodontitis (NP) Affected tissues Gingival tissues Gingival tissues and underlying hard tissue Severity Less severe More severe Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

27. Clinical features (NG): N ecrosis of the interproximal papillae Spontaneous gingival bleeding Pseudomembranous necrotic covering of the marginal tissue Other clinical signs and symptoms of NG: Poor appetite Fever up to 40°C (104°F) General malaise Regional lymph nodes Fetid mouth odor (Halitosis) Sialorrhea (in children) Predominant microorganisms in NG lesions: Prevotella intermedia Fusobacterium Treponema Selenomonas species Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

28. Treatment: If the gums are severely inflamed : First visit: gentle supragingival debridement (scaling) and antibiotics are indicated. Second visit: Supragingival and subgingival debridement (scaling and root planing ) and mild oxidizing solutions help heal the gums within 24-48 hours . If the gums are mild to moderate inflamed : First visit: Supragingival and subgingival debridement (scaling and root planing ) and mild oxidizing solutions help heal the gums within 24-48 hours. In both cases: Improved oral hygiene, mild oxidizing mouthrinses after meals, and twice-daily rinsing with chlorhexidine (CHX) are necessary for long-term healing Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

29. T he differences between necrotizing gingivitis (NG) and acute herpetic gingivostomatitis (AHG): Feature NG AHG Ulcer location Gums Lips and cheeks Ulcer appearance Crater-like with pseudomembranous slough Round with red areolae Therapeutic debridement Effective Ineffective Antibiotic therapy Effective Ineffective Age group Children and young adults Preschool children Onset Gradual Rapid Association with plaque and poor oral hygiene Yes No Association with xanthomatosis Yes No Associated with Langerhans cell histiocytosis Yes No Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

30. ACUTE CANDIDIASIS (THRUSH, CANDIDOSIS, MONILIASIS) Candida albicans is a common inhabitant of the oral cavity but may multiply rapidly and cause a pathogenic state when host resistance is lowered. Causes: long-term oral steroid. Long-term antibiotic therapy Clinical feature: R aised , furry white patches, which can be removed easily to produce a bleeding underlying surface. Neonatal candidiasis , contracted during passage through the vagina and erupting clinically during the first 2 weeks of life, is a common occurrence. This infection is also common in immunosuppressed patients. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

31. Age Group Treatment Infants and very young children Nystatin suspension 1 mL (100,000 units) four times a day. (oral drops) Clotrimazole suspension (10 mg/mL), ( 1–2 mL) four times a day. (oral drops) Systematic fluconazole suspension (10 mg/mL) at a total dosage of up to 6 mg/kg/day Children old enough to manage solid medications allowed to dissolve in the mouth Clotrimazole troches or nystatin pastilles Children old enough to swallow Systemic fluconazole (100-mg tablets) in a 14-day course Treatment : Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

32. ACUTE BACTERIAL INFECTIONS For example: Acute streptococcal gingivitis The prevalence : unknown . Clinical features : enlarged papilla. gingival abscesses. painful , erythematous gingiva and bleeding. Diagnosis: difficult without laboratory tests. Treatment: Antibiotics, if the infection is believed to be bacterial in origin. Improved oral hygiene, CH mouthrinses are also appropriate. Çiçek Y, Ozgoz M, Çanakçi V, Orbak R. Streptococcal gingivitis: a report of case with a description of a unique gingival prosthesis. J Contemp Dent Pract . 2004 Aug 15;5(3):150-7.

33. Chronic Nonspecific Gingivitis Seen during: the pre-teenage and teenage years. M ay be: localized to the anterior region or more generalized . Clinical features: Fiery red gingival lesion. Not enlarged interdental labial papillae. Rarely painful, persists for long periods without much improvement (Fig . 15.15 ). Diagnosis: Histologic examination: ruled out a bacterial infection . Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

34. Potential causes: Inadequate oral hygiene hormonal imbalance .( due to age of the patients involved and the prevalence of the disease in girls) dietary inadequacies ( vitamin deficiency) Malocclusion . (hinders proper oral hygiene and plaque removal) Caries lesions with sharp edges and faulty restorations with overhanging margins. (cause food to accumulate) mouth breathing. responsible for the chronic hyperplastic gingivitis in the maxillary arch. Treatment: Proper oral hygiene daily. M ultivitamin supplements. Restore the defective teeth after the reduction of acute symptoms Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

35. Gingival Diseases Modified by Systemic Factors GINGIVAL DISEASES ASSOCIATED WITH THE ENDOCRINE SYSTEM puberty gingivitis : It is a subtype of gingivitis that commonly affects children in: P repubertal . C ircumpubertal periods. It is caused by a combination of factors, including : Dental plaque:  The primary etiologic factor.  the inflammation is confined to the marginal gingiva without affecting the attachment levels and crestal bone levels. Hormonal fluctuations:  Hormonal fluctuations that occur during puberty can exaggerate the degree and severity of inflammation. Gender:   Girls tend to reach their maximum puberty gingivitis experience earlier than boys . Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

36. Clinical features” The enlargement of the gingival tissues in the anterior segment and may be present in only one arch. The lingual gingival tissue remains unaffected (Fig. 15.17A and B). Treatment : Improved oral hygiene , removal of all local irritants, R estoration of carious teeth . Dietary changes necessary to ensure an adequate nutritional status. O ral administration of 500 mg of ascorbic acid is taken for approximately 4 weeks Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

37. Diabetes gingivitis: Main types : Type 1:  Immune system destroys beta cell (insulin-dependent) Type 2:  Most common type, caused by insulin resistance and deficiency Gestational:  Develops during pregnancy, usually goes away after birth Some subtypes Neonatal :  Develops in infants under 6 months, caused by genetic mutations and chromosomal abnormalities Secondary:  Caused by another medical condition, such as Cushing's syndrome or acromegaly Periodontal complication: exaggerated inflammatory response to dental plaque, which can lead to gingivitis and periodontist. the concept that an imbalance in glucose metabolism predisposes an individual to gingival inflammation which, in turn, lowers host resistance to plaque. American Diabetes Association. Standards of medical care in diabetes—2023. Diabetes Care. 2023;46(Suppl. 1):S1-S265.

38. GINGIVAL LESIONS OF GENETIC ORIGIN Hereditary gingival fibromatosis (HGF ): It is a slowly progressive, benign enlargement of the gingiva. Clinically: The gingiva has a normal healthy color, Firm consistency, non-hemorrhagic, and is asymptomatic Equal gender predilection. Etiology: It is an autosomal dominant genetic disorder. It has been referred to as elephantiasis gingivae or hereditary hyperplasia of the gums . Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

39. Characterization of (HGF ): The gingival tissues appear normal at birth, but they begin to enlarge with the eruption of the primary teeth. The gingival tissues usually continue to enlarge with eruption of the permanent teeth until the tissues essentially cover the clinical crowns of the teeth. Complication: Displacement of the teeth and malocclusion. The condition is not painful until the tissues partially covers the occlusal surfaces of the molars and is traumatized during mastication. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

40. Treatment: Surgical removal of the hyperplastic tissue Note: hyperplasia can recur within a few months and can return to the original condition within a few years. The importance of excellent plaque control to reduce recurrence of the gingival overgrowth Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

41. PHENYTOIN-INDUCED GINGIVAL OVERGROWTH phenytoin (Dilantin, or diphenylhydantoin), an anticonvulsant for epilepsy, induced gingival overgrowth. Prevalence : study reporting 0%-95% and other investigators reporting 40%-50%. PIGO develops: within 2-3 weeks of starting phenytoin therapy and peaks at 18-24 months Contributor factors: The dosage level : The higher dose you take, the more likely to develop PIGO . Plaque (local irritants) and PIGO: supported by the observation that phenytoin patients without teeth almost never develop PIGO . Oral hygiene: oral hygiene can help to prevent or suppress PIGO. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

42. C linical appearance: Asymptomatic enlargement of the interproximal gingiva Buccal and anterior segments are more often affected than the lingual and posterior segments Affected areas are localized at first, but can become more generalized later Gingiva appear pink and firm and do not bleed easily when probed As the interdental lobulations grow, develop clefting at the midline of the tooth, (join together) at the midline, forming pseudopockets Epithelial attachment level usually remains constant (the gums do not recede) In some cases, the entire occlusal surface is covered The gingival overgrowth may remain purely fibrotic or may be inflammated . Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

43. Complication: U naesthetic appearance. Difficulty in mastication. Speech impairment. Delayed tooth eruption. Tissue trauma. Secondary inflammation leading to periodontal disease . Steinberg46 recommended the following types of dental treatment based on clinical oral signs and symptoms: Mild PIGO (less than one third of the clinical crown is covered): Daily meticulous oral hygiene More frequent dental care Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

44. Moderate PIGO (one- to two-thirds of the clinical crown is covered) : Meticulous oral home care U se of an irrigation device with antiplaque mouthrinse (0.12% CH gluconate) Four weekly office visits for cleaning and Stannous fluoride application. In the fifth week, evaluate the gingiva size and check the phenytoin level . ( normal therapeutic range is 10–15 mg/mL ). if no improvement: Consultation with the patient's physician to consider switching to a different anticonvulsant drug Surgical removal of the overgrowth Severe PIGO (more than two-thirds of the tooth is covered) : Surgical removal. Regardless of severity: Meticulous supragingival and subgingival scaling before surgery Meticulous oral hygiene after surgery Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

45. After surgery to reduce or prevent phenytoin-induced gingival overgrowth (PIGO ), may we use: Pressure appliances folic acid therapy Other medications induce gingival overgrowth in some patients include : Cyclosporine. C alcium channel blockers. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

46. SCORBUTIC GINGIVITIS Definition: Scrobutic gingivitis is associated with vitamin C deficiency and differs from dental biofilm-induced gingivitis . Prevalence: reporting indicates is low. Features and symptoms: Inflammation and enlargement of the marginal gingival tissue and papillae A bsence of local predisposing factors as evidence of scorbutic gingivitis. S evere pain and spontaneous hemorrhag . Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

47. ascorbic gingivitis can be seen in : both pediatric and adult cancer patients undergoing radiotherapy and/or chemotherapy where: the mucosal linings of the intestinal walls are affected. the absorption of nutrients is impaired. diagnosis: Blood test to confirm vitamin C deficiency and exclude other systemic conditions Q uestioning child and adult caregivers about eating habits and dietary intake to identify inadequate intake of vitamin C-rich foods treatment For young children: daily administration of 250-500 mg of ascorbic acid For older children and adults: 1 g of vitamin C for 2 weeks Complete dental care, improved oral hygiene, and supplementation with vitamin C and other water-soluble vitamins to improve gingival condition Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

48. Periodontal Diseases in Children Periodontitis is an inflammatory disease that affects the gingiva, the cementum, PDL, and the alveolar bone. Clinical features: P ocket formation. CAL. D estruction of the supporting alveolar bone . Diagnosis: Bitewing radiographs to assess BL ( measuring the height of the alveolar bone relative to the CEJ): Questionable BL : 2-3 mm. definite BL : >3 mm Periodontal probing to confirm BL , between the first and second primary molars. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

49. Periodontitis (previously called aggressive periodontitis and early onset periodontitis). Periodontitis can occur in younger people, regardless of their overall health. There are two categories: a localized form, i.e., molar-incisor distribution (previously called localized aggressive periodontitis [LAP] and localized juvenile periodontitis ). a generalized form (previously called generalized aggressive periodontitis [GAP]). Contributor factors Abnormalities in host defenses (e.g., leukocyte chemotaxis ). a family history of periodontitis extensive proximal caries facilitating plaque retention and BL. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

50. Generalized periodontitis The onset: is during or soon after the eruption of the primary teeth. Clinical features: severe gingival inflammation. generalized attachment loss. tooth mobility. rapid alveolar BL with premature exfoliation of the teeth. May be by 3 years of age. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

51. Periodontitis with molar-incisor distribution. Occurrence : Affects healthy children and adolescents. The onset time : around or before 4 years of age . Clinical feature: A ttachment loss and alveolar BL localized to the molars and incisors. Vertical BL Less tissue inflammation. V ery little supragingival and subgingival dental plaque or calculus. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

52. TREATMENT OF GENERALIZED PERIODONTITIS AND PERIODONTITIS WITH A MOLAR-INCISOR DISTRIBUTION Successful treatment depends on : Early diagnosis. The use of antibiotics against the infecting microorganisms. S upragingival and subgingival scaling via nonsurgical and/or surgical treatment modalities with or without adjunctive antimicrobial therapy. Reinforcement of meticulous home care. Strict periodic follow-ups to monitor patient compliance and intercept disease recurrence at its early stage . Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

53. Consultation with the patient's doctor and additional diagnostic tests may be needed to rule out: systemic conditions that can cause periodontitis (e.g., cyclic neutropenia, histiocytosis ). conditions that affect the periodontal tissues (e.g., diabetes, hyperparathyroidism ). Steps of treatment: Scaling and root planing Adjunctive antimicrobial therapy with amoxicillin and metronidazole for 1-2 weeks. Tetracycline use in children and pregnant/breastfeeding women should be avoided due to the risk of tooth discoloration and fetal developmental issues, including skeletal system development. Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2.

54. References: Berglundh T, Armitage G, Araujo MG, Avila-Ortiz G, Blanco J, Camargo PM. Classification of Periodontal and Peri -Implant Diseases and Conditions. J Periodontol . 2018;89:S313-8. American Academy of Pediatric Dentistry. Classification of periodontal diseases in infants, children, adolescents, and individuals with special health care needs. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2023:493-507 Dean JA, editor. McDonald and Avery's dentistry for the child and adolescent-E-book. Elsevier Health Sciences; 2022 Feb 2. Çiçek Y, Ozgoz M, Çanakçi V, Orbak R. Streptococcal gingivitis: a report of case with a description of a unique gingival prosthesis. J Contemp Dent Pract . 2004 Aug 15;5(3): 150-7. American Diabetes Association. Standards of medical care in diabetes—2023. Diabetes Care. 2023;46(Suppl. 1):S1-S265.